Sex Offender Treatment

ABSTRACT: For those convicted of sex crimes, probation
with mandated treatment along with some jail time is a common disposition.
The major goal of treatment for sex offenders is the prevention of sexual
offenses in the future. However, until recently there has been little
evidence that treatment reduces recidivism. The type of treatment which is
most likely to succeed is an individually-tailored approach that includes
careful assessment and uses a broad mix of cognitive-behavioral techniques to
support individual behavior change. There is little evidence for the
effectiveness of many commonly-used treatment approaches.

Psychotherapy is often ordered for child sexual abuse
perpetrators. Of possible treatment modalities, the most common approach has
been group therapy that relies heavily upon punitive and hostile confrontation
and a nonsystematic blend of psychoanalytic concepts and traditional talking
therapy. There is often little or no effort to provide a theoretical base for
the program. The result is a procedure that is essentially highly moralistic and
reflects the judgmental emotional response of the society rather than an
empirically-based healing technique.

Treating people with disordered behavior patterns as morally
defective and requiring a change in moral commitments has a long history (Siegler
& Osmond, 1974). However, moral treatments, such as those currently vended
for perpetrators of child sexual abuse, should be labeled for what they are.
It
is professionally irresponsible to call a procedure therapy, implying it is
value free, when, in fact, it is based upon moral values and pursues goals
defined moralistically.

Psychotherapy is a venture much studied and researched and
there is an extensive literature on psychotherapy processes and outcomes. There
is sufficient information to have some understanding of what may actually work
to change behavior. The scientific knowledge available permits more than an educated guess or a
trial and error methodology. Unfortunately, many current treatment programs for
sexual abusers fall to use techniques known through research to be effective.

The effectiveness of therapeutic treatment is often measured
by its contribution to restoration of emotional health and normal functioning
along with the subjective sense of well-being of the individual. Normal behavior
may be defined either by reference to the applicable social norms or by
statistical frequency. With treatment for a person guilty of child sexual abuse
the essential goal is the prevention of sexual offenses in the future. Subjective well-being or conformity to generally accepted norms in other areas
is not sufficient to measure treatment outcomes.

In providing treatment to persons accused and/or convicted of
child sexual abuse, the situation can be complicated by a number of factors.
When a person is accused of sexual abuse, the accusation is either true or it is
not true and the accused may admit or deny the accusation. But there also may be
plea bargaining, dropping of charges for insufficient evidence, dismissal by
stipulation in family court, admission of guilt, admission of a mistake by the
social service agency, and acquittal by the criminal court along with a finding
of abuse by family court. An accused person may be required to enter a treatment
program as a sexual abuser long before there is a determination by the justice
system about the accusation. Often this is a requirement laid down by child
protection as a precondition for a parent to have contact with his or her
children. For many parents this is a highly coercive demand. It is difficult to
imagine a more powerful club to hold over parents who love their children.

Such events confront the therapist with a complex situation. Determining what is to be treated may not be easy.
There are many permutations
of the interaction of truth or falsity, denial and admission, and substantiated
or unsubstantiated allegations in people entering sex offender treatment
programs. The most difficult is the situation of a person accused who in reality
did not do it, denies it, but the accusation is substantiated or the court rules
that the abuse had occurred.

Furby, Weinrott, and Blackshaw (1989) note that for those
convicted of sexual crimes, probation with mandated treatment and perhaps some
jail time is the most common disposition. Also, a person accused of sexual abuse
may be offered a choice of therapy in place of punishment. The offer may be made
in criminal court or in juvenile and family court. In a divorce or custody
battle the parent initiating the allegation may offer to restore visitation if
the accused parent admits guilt and successfully completes the treatment
program. In criminal court, the defendant may be offered a plea bargain in which
he is put on probation in exchange for entering a treatment program. He
therefore avoids risking criminal conviction and years in prison. The deal
offered is that entering sexual offender treatment will mean avoiding highly
aversive consequences such as imprisonment, loss of relationships with children,
loss of career or job, financial ruin through an expensive trial, and
embarrassing publicity.

The subtleties of such a deal are that apparently everybody
wins. But there is a negative effect upon the process of therapy, as Langevin
(1983) points out:

Often the imposition of external force to be treated is
unsatisfactory and a poorer treatment outcome can be anticipated ... Court
orders for treatment as opposed to jail or in addition to jail make it hard to
enact any worthwhile treatment program because treatment becomes a sentence
rather than a therapy (p.64).

When a person is sentenced to sex offender treatment as part
of a plea bargain or sentencing, the therapy itself may become punishment.
The
person is ordered to attend treatment with an indeterminate sentence and usually
cannot select the therapist or the program; therapy programs must be approved by
the agencies in control. The distortions and dangers inherent in this situation
are reflected in the formation of a group of psychologists in Washington who
have initiated a class action lawsuit against the state and against prosecutors
who have limited sexual offender treatment programs to a small group approved by
the system (Deatherage, 1990).

The therapist who provides such court-ordered treatment for
sexual offenders must make regular reports to parole officers, judges, and child
protection workers. The therapist is given the power to judge when the treatment
has been successfully completed and discharge is granted. This puts the
therapist in the role of the jailer. Also, any information given by the sex
offender about other victims or offenses must be reported by the therapist.
Langevin and Lang (1985) comment that a therapist who serves both as
helper-therapist and as informer for the law becomes a "double agent."

This difficulty is illustrated by a recent Minnesota case. The client, who was in a sex offender treatment program following his conviction
for rape, was asked as part of the treatment to write detailed accounts of other
times in which he had sexually assaulted women. He complied and produced a
written account of several other incidents. This was then given to the police by
the probation officer. The man was later convicted on the basis of this
written
account and sentenced to nine years in prison (Zack, 1990).

These circumstances also provide a subtle opportunity for any
hostility or pathology in a therapist to affect the therapist's behavior and the
process of therapy. The research in sensitivity groups (Lieberman, Yalom, &
Miles, 1973) demonstrates the damage a hostile therapist can do to vulnerable
group members. A hostile therapist can cause serious emotional harm to patients.
The seductiveness of the powerful level of control available to a therapist can
cause the therapy to be destructive and damaging. Countertransference by a
therapist must be actively considered, examined, and dealt with when found to be
present.

If an admission of guilt is required before being admitted
into a program, additional complications and potential hindrances to successful
treatment are generated. There are no empirical data to demonstrate that a
threshold admission of guilt has any relationship to outcomes. It may, however,
prevent both actual perpetrators and innocent people from being able to progress
in resolution of their individual situations. It may increase the likelihood of
error in the justice system.

When an accused person who is actually innocent enters
treatment with the hope of eventually having a relationship his children or of
getting some benefit from therapy, it can be disastrous. Successful completion
of treatment is often defined by the requirement that the accused admit guilt.
It cannot be a general, bland admission, "Yes, I am an abuser," but
often must be specific, detailed, given regularly in group, and may include an
admission and apology to the victim.

Patton (1990) observes that if the court sustains a
dependency petition, it can require that the parents cooperate in psychotherapy
and can rule that failure to admit the abuse is sufficient evidence to warrant
continued foster care or termination of parental rights. He states, "There
is really no dispute regarding the coercive nature of requiring parents to
confess in court-ordered therapy as a condition for regaining child
custody" (p.515). At the same time, in almost all jurisdictions, the
prosecutor in any pending criminal case has access to statements made during the
therapy ordered by the family court. Therefore, an accused person is put into a
situation where if he remains silent in therapy, he may lose his child, but if
he confesses the abuse, he provides the prosecutor with damaging
evidence. He must waive his fifth amendment rights in order to protect his
fundamental right to have a relationship with his child.

Treatment and Recidivism

The most important goal of treatment for sex offenders is
that they refrain from committing sex offenses in the future. This goal is more
important than emotional health or adjustment, self-esteem, feelings of
well-being, self-actualization, reported satisfaction with therapy, or
improvement as measured by psychological tests.

Until recently there has been little evidence that treatment
reduces recidivism. In a review of the research on the treatment of sexual
abusers, Finkelhor (1986) concludes:

Unfortunately, the available studies tell us very little
about what is perhaps the most important question: Does treatment reduce
recidivism?... The recidivism rates for the treated groups are
not consistently better than the nontreated groups ... So it cannot be said
that ... (anybody's) recidivism study provides strong evidence in favor of
the positive effects of treatment (pp.136-137).

A more recent review of sex offender recidivism (for all sex
offenses, not just child sexual abuse) by Furby et al. (1989) reaches a similar
conclusion. These reviewers critically examined 42 empirical studies of sex
offender recidivism and report that the recidivism rates ranged from 0% to over
50%. They found little consensus about the continuance of sexual offenses
following treatment and conclude that there is no evidence that clinical
treatment effectively reduces recidivism. Also, there are no data at present for
assessing the relative effectiveness of treatment for different types of
offenders.

However, the authors report that the methodological
weaknesses and lack of uniformity in the recidivism studies make it difficult to
discern patterns or draw conclusions from them. In addition, they note that
treatment models have been evolving constantly and many of those in the studies
they reviewed are now considered obsolete. Pithers and Cumming (1989) state that
Furby et al. believe that outcome data from specialized treatment programs for
sexual offenders will demonstrate therapeutic efficacy. In fact, initial data on
the Vermont cognitive-behavioral relapse prevention program (Pithers &
Cummings, 1989, discussed below) is promising.

A recent study by Hanson, Steffy, & Gauthier (1990) on recidivism examined offenders from 3 to 23 years
after treatment. The treatment was a short-term, multimodal program and
recidivism was assessed through records of reconvictions. The researchers report
that 44.3% of their total sample of 106 child molesters were reconvicted with
9.4% of the total sample being reconvicted between 10 and 23 years after being
released. Incest perpetrators were reconvicted at the slowest rate (21%),
homosexual pedophiles at the highest rate (66.7%), with heterosexual pedophiles
and undifferentiated offenders showing an intermediate rate (42.2% &
36.36%). This study demonstrates the importance of extending the follow-up
period when examining recidivism.

Sexual offenders now account for an average of 10% of the
prison population of the United States, with some jurisdictions reporting rates
as high as 21% (Borzecki & Wormith, 1987). In 1988, sex offenders
constituted the largest single group of inmates in Minnesota (Prince, 1988).
The
difficulty in treating persistent and dangerous offenders against children is
illustrated by Crawford (1981) who concludes that only castration has been found
to be successful in preventing recidivism for this population. Recidivism rates,
although variable, suggest that incarceration alone is not sufficient. The
necessity to do something besides warehouse sex offenders in prison until they
are released, unchanged, led people to conclude that treatment must be offered.
Therefore, treatment programs developed to fill this need.

Traditional Offenders Program

Most treatment programs for sex offenders insist at the onset
that the perpetrator admit guilt as a condition of acceptance into the program.
Therefore, if an innocent person plea bargains and agrees to treatment, the
person must admit guilt to be admitted into the program. If guilt is not
admitted, the probation is violated and the person may be sent to jail. This
requirement is widespread, although there are a few treatment programs which do
not require this threshold admission of guilt (Blush & Ross, 1986; Brown,
undated; Krop 1986; Lampel, 1986; Langevin, 1989; Simkins, Ward, Bowman, &
Rinck, 1990; Underwager & Wakefield, undated).

Group therapy is seen as the most appropriate form of
treatment in the United States (Borzecki & Wormith, 1987). The rationale for
this is the argument that sex offenders require group therapy because effective
confrontation of manipulative behavior can only be done by other individuals who
have been through the same dynamic. It is assumed that all sexual abusers are
skilled at manipulation and will demonstrate manipulativeness. It is also
assumed they must stop being manipulative. Groups are seen as necessary and
appropriate for all sexual offenders, regardless of their individual
personalities and the factors underlying their abusive behavior.

The expression of feelings is absolutely required. Cognitive,
learning theory-based approaches therefore may be seen as a way of allowing the
accused to avoid dealing with feelings of remorse, guilt, or shame which are
considered to be essential parts of treatment. Common treatment goals include
bringing the perpetrator to the point where he admits all of his abusive
behaviors, expresses guilt and remorse for them, and is willing to admit and
apologize to the victim. These are moralistic goals with no demonstrated
relationship to outcomes.

The therapist must be authoritarian and allied with the
justice system. Sgroi is often cited to support the demand for therapy to be
highly authoritarian. Sgroi (1982) believes that effective treatment can only be
accomplished in an authoritative fashion and from a position of power. She
believes that anything else invites the abuser to misuse power to suppress the
allegation and undermine the child's credibility. The necessary submission to
authority in treatment is demonstrated by compliance with the demands of the
program for completion of all assignments, attendance, and sobriety. This
usually includes meeting stages of performance that show progress through the
treatment.

There is no evidence for the effectiveness of this type of
treatment to cure sexual abuse and prevent recidivism. There is no support for
the assertion that such therapy is the only right way to treat sex offenders.
Nevertheless, this approach is the type of intervention generally insisted upon
by the system.

Quinsey, in 1977, commented on the research supporting the
use of group therapy for child molesters:

Group therapy remains the most widely used treatment for
child molesters. However ... the therapy approaches described in the
literature appear to be based on contradictory premises. Furthermore, few data
have been reported to indicate that changes occur within these groups, and no
studies have been conducted that compare group therapy to other types of
treatment. An additional difficulty is that the description of the treatment
method itself in these studies is at such a general level that replication of
them would appear to be impossible (p. 213).

This conclusion remains true today. There is no empirical
support for the belief that groups are more effective in confronting attempted deception or manipulation.
A study by McCaghy (1967) showed that child abusers in therapy readily adopt the
language and rhetoric of the therapist to describe and account for their abuse.
Those that were in many therapy sessions changed their explanations of their
behavior to include descriptions of their early childhood, exposure of personal
weaknesses, and use of mental health terminology. Often child abusers report the
sexual preferences they know therapists want to hear in order to obtain an early
release or to meet the therapist's expectations.

Marcus (1970) and Marcus & Conway (1971) report on a
group therapy treatment program they ran in the Canadian prison system. They
state that groups construct a dynamic defense against the therapist to prevent
knowledge and identification of group members who deteriorate or really don't
change.

Collectively group therapy studies of pedophilia has (sic)
been poorly delineated without reference to the direction of treatment or
theoretical characteristics of the pedophile which are the targets of
treatment. Follow ups were short and assessments so general that the
effectiveness of this procedure is uncertain. The poor outcome of group
therapy with exhibitionism (Chapter 10) which could be traced might serve as
a guide to the use of this approach (p. 292).

There is a lack of credible research on the treatment for
child sexual abusers (Borzecki & Wormith, 1987; Furby et al., 1989). There
are few reports that compare different treatments, use control groups, have
adequate outcome measures, or include follow-up data. Many are nothing more than
case reports that do not even follow accepted single case design standards.
The
case studies are unsystematic, uncontrolled and so confounded that no variables
can be seen to be operative in treatment outcomes. There is no report that meets
all of the criteria for well-designed and scientifically credible research.

Treatment Directions With Research Support

The therapy modalities that have been used in treating child
sexual abusers include behavior therapy with many classical and operant
conditioning techniques, hypnotism, psychoanalysis, traditional talking
psychotherapy, group therapy, chemical interventions, castration,
electroconvulsive therapy (ECT), and psychosurgery. Langevin (1983) reviews and
evaluates each of these modalities. Although aware of the criticisms that have
been leveled against behavior therapy, he believes that the principles of
behavior therapy should be followed. He also recommends using the assessment
methods developed by behavior therapists.

Langevin and Lang (1985) maintain that "sexual
preference is a powerful and persistent feature of human behavior and there is
no evidence that therapy in any form can change it" (p.409). Therefore the
goal of therapy must be to help the pedophile manage his urges for sexual
contact with children. A key factor in the success in any treatment of
pedophiles will be motivating them to change; most pedophiles are resistant to
giving up a sexual behavior pattern which they perceive as positive and
rewarding. Pedophiles often initially deny, minimize, or rationalize their
abusive behaviors and the first goal of treatment must be to get the offenders
to admit their past behaviors and overcome their rationalizations.

We recommend an individually-tailored approach that includes
careful assessment of the situation along with the capacities, personality, and
behaviors of the individual and a therapy program that uses a broad mix of
learning theory-based treatment techniques to support individual behavior
change. Different treatment interventions must be planned for different types of
child molesters. Such an approach has the best research support.

The implications of the research lead Quinsey (1977) to say
"... treatment programs should be individualized" (p.216). Lampel
(1986) reports on the success of individualized treatment approaches. Giarretto
(1976) emphasizes individualized treatment. Dixen and Jenkins (1981) recommend
an individualized multi-component therapy approach. Langevin (1983) sees
individualized behavior therapy techniques as the treatment of choice. Borzecki
and Wormith (1987) state that "Individually tailored treatment is commonly
lacking in the voluntary American programmes; here is an obvious source of
concern, since treatment needs vary tremendously across offenders" (pp.
34-45).

Although there are little outcome data on treatment for
sexual offenders, the approach that is most supported by what data are available is cognitive-behavioral
(Anderson & Shafer, 1979; Dixen & Jenkins, 1981; Langevin, 1983;
Quinsey, 1977). A large number of specific techniques and methods are included
in the therapy possibilities that learning theory and a cognitive-behavioral
strategy generate. The therapist can construct a highly individualized and
flexible treatment approach which can be changed and refined as treatment
progresses. An important component of a behavioral therapy is social skills
training to redress the weakness and inadequacies of child molesters in adult
interactions (Dwyer & Amberson, 1985; Langevin, 1983; Overholser & Beck,
1986; Quinsey, 1977). Dwyer (1990) reports a significant reduction in paraphilic
fantasies following a treatment approach which includes a broad range of
techniques including cognitive restructuring, social skills training,
psychodynamic treatment, and family therapy. Annon (1989) reports a 85% to 95%
success rate with an individualized treatment approach which uses
behavioral/cognitive methods.

While not directly dealing with child sexual abusers, there
is good research dealing with rehabilitation of offenders generally. For some
time rehabilitation has been seen negatively because the idea spread that it
didn't work. Now there is evidence about the factors present when therapy
doesn't work and factors present when it does work. This knowledge is applicable
to the treatment for sexual abusers.

Lipton (1986) identified recurrent problems that can lead to
the failure of any rehabilitation effort. They include 1) hostility to change,
2) a coercive correctional system, 3) lack of any theoretical base for the
treatment program, 4) failure to implement the program fully, and 5) inability
to relate to the world beyond the institution. Gendreau (1986), after a decade
of research, adds that unsuccessful programs use approaches that are
inappropriate for the offender, rigid, imposed from the top down, and use only
negative reinforcers. He described what makes a rehabilitation program work:

Effective programs tend to follow a social learning,
cognitive behavior theory type of approach, as opposed to a psychodynamic
model. ... But they are more flexible and less mechanistic than early behavior
modification and contingency management approaches ... They maintain
authority not by bashing heads, but by setting limits and enforcing probation
orders and other rules. They adopt a problem solving approach, with positive
modeling, and make extensive use of community resources. They build on the
quality of interpersonal relationships, and they try to mediate between the
needs of the client and what exists in the real world (p.14).

More recently, Gendreau reports that his research indicates "appropriate" treatment programs reduce
recidivism rates by 53%. The most successful programs are those that employ
behavioral modification techniques that reward pro-social behavior and target
antisocial attitudes and values that fuel criminal behavior. Effective
rehabilitation programs teach offenders skills they can use to keep from
reoffending (reported by Freiberg, 1990).

There is sufficient research to conclude that the most
effective treatment for child sexual abusers is individualized, uses
cognitive-behavioral techniques, and is adaptive and flexible. While more
research is needed, the clinician who must provide treatment can do a better job
by following these directions.

Treatment for persons accused of child sexual abuse must also
consider the situation of an innocent person who is accused. Although denial,
minimization, and rationalization are found in actual sex offenders, there is
always the possibility that a person maintaining denial is innocent. This is apt
to be more likely when there is a plea bargain or no adjudication. However, even
people who continue to deny abuse after being criminally convicted may, in fact,
be innocent. There is no way to know how often this happens, but it does happen,
and clinicians providing treatment should not automatically assume that all
persons who deny abuse are unmotivated and defensive abusers.

Relapse Prevention

Relapse prevention is a self-control program designed to
teach individuals who are trying to change their behavior how to anticipate and
cope with the problem of relapse. It developed within the area of addictive
disorders but has been expanded to sex offenders. It is based on social learning
theory and combines behavioral and cognitive interventions. There is an emphasis
on self-management. It is not an isolated treatment; relapse prevention was
developed as a maintenance strategy and is intended to preserve gains in
whatever treatment preceded it (George & Marlatt, 1989; Laws, 1989).

The relapse prevention program is individually developed
following a careful assessment of the individual. Cognitive-behavioral
techniques such as aversive conditioning, cognitive restructuring, thought
stopping, covert sensitization, satiation, contracts, covert reinforcement,
modeling, role playing, social skills training, and relaxation training are
used. Offenders learn to identify and anticipate high risk situations, control
their urges, develop more effective coping skills, maintain a more balanced
lifestyle and gain a sense of control and self-efficacy. Through this
process, it is hoped that they will be less apt to relapse and recommit a sexual
offense.

Three treatment programs using this approach are described in
Laws' book, Relapse Prevention With Sex Offenders (1989). These programs are The
Sex Offender Treatment and Evaluation Project at Atascadero State Hospital in
California, The Center for Prevention of Child Molestation at the Florida Mental
Health Institute in Tampa, and The Vermont Treatment Program for Sexual
Aggressors. Laws points out that these programs are "highly
unrepresentative" and their generalizability is limited. However, they do
represent what can be done with adequate resources and heavy reliance on the
concepts of relapse prevention.

Only the Vermont program (Pithers & Cumming, 1989) reports follow-up data as the other programs are
too new. On a six-year follow-up on recidivism for 167 offenders who attended the program in 1982, there was
a 4% recidivism rate for the group as a whole. This differed for rapist and pedophiles, with a rate of 3% for
pedophiles (4 out of 147) and 15% for rapists (3 out of 20).

Pithers and Cumming then compared this to the recidivism on a
five-year follow-up on sex offenders who were treated with a standard peer-group
milieu therapy at Atascadero Hospital (this was the old treatment program,
before relapse prevention was instituted). There was no significant difference
in recidivism between the Atascadero rapists and the Vermont rapists (26% versus
15%), but there was a highly significant difference for the pedophiles. While
only 3% of the Vermont pedophiles relapsed, 18% of the Atascadero pedophiles
reoffended.

These results suggest that an individually tailored
cognitive-behavioral treatment approach for child sexual abusers has the best
chance of succeeding in reducing recidivism. The relapse prevention model
appears to be a promising treatment approach, although more data are needed in
order to generalize the results of this outcome study.

Conclusions

There is a need for effective treatment programs for those
who sexually abuse children. Many commonly used treatment programs are not
supported by research evidence and have no demonstrated efficacy. There is
sufficient research to have confidence in programs that are individualized,
cognitive-behavioral, flexible, and related to the real situation of the abuser.

References

Annon, J. S. (1989, April). Assessing and treating sex
offenders: Training and videotape demonstration. Presentation made at
the Fifth Annual Symposium in Forensic Psychology of the
American College of Forensic Psychology, San Diego.